Birth trauma
ICD-10 Codes (43)
P11P11.0P11.1P11.2P11.3P11.4P11.5P11.9P12P12.0P12.1P12.2P12.3P12.4P12.8P12.81P12.89P12.9P13P13.0P13.1P13.2P13.3P13.4P13.8P13.9P14P14.0P14.1P14.2P14.3P14.8P14.9P15P15.0P15.1P15.2P15.3P15.4P15.5P15.6P15.8P15.9Updates & Changes
FY 2026 Updates
New Codes (1)
Revised Codes (1)
Deleted Codes
No codes deleted in this range for FY 2026
Historical Changes
- •FY 2025: Routine maintenance updates with minor terminology clarifications
- •FY 2024: Enhanced specificity requirements for certain code ranges
- •FY 2023: Updated documentation guidelines for improved clarity
Upcoming Changes
- •Proposed updates pending review by Coordination and Maintenance Committee
- •Under consideration: Enhanced digital health integration codes
Implementation Guidance
- •Review all FY 2026 updates for P10-P15 codes before implementation
- •Always verify the most current codes in the ICD-10-CM manual
- •Ensure clinical documentation supports the selected diagnosis codes
- +3 more guidance items...
Range Overview
The ICD-10 category P10-P15 pertains to birth trauma. These codes are used to document injuries to the infant that occur during the birthing process. The range includes specific codes for injuries to the scalp, skull, brain, peripheral nervous system, and other injuries related to birth trauma.
Key Usage Points:
- •Always code to the highest level of specificity.
- •Use additional codes to identify any associated conditions.
- •Consider the use of external cause codes to provide additional details.
- •Remember to code for any complications arising from the birth trauma.
- •Always verify the codes with the latest ICD-10-CM manual.
Coding Guidelines
When to Use:
- ✓When an infant has sustained a skull fracture during birth.
- ✓When an infant has experienced brain damage due to birth trauma.
- ✓When there is a peripheral nervous system injury due to birth trauma.
- ✓When an infant has sustained other injuries related to birth trauma.
- ✓When an infant has sustained multiple injuries during birth.
When NOT to Use:
- ✗When the infant has not sustained any injuries during birth.
- ✗When the infant's injuries are not related to the birthing process.
- ✗When the infant's injuries are due to congenital conditions.
- ✗When the infant's injuries are due to postnatal causes.
Code Exclusions
Always verify the exclusions with the latest ICD-10-CM manual.
Documentation Requirements
Documentation for birth trauma should be detailed and include the specific type of injury, the cause of the injury, and any associated conditions or complications. The documentation should also include the infant's birth weight and gestational age.
Clinical Information:
- •Specific type of injury
- •Cause of the injury
- •Associated conditions or complications
- •Infant's birth weight
- •Infant's gestational age
Supporting Evidence:
- •Medical history
- •Clinical examination findings
- •Diagnostic test results
- •Treatment plans
Good Documentation Example:
Infant sustained a skull fracture during a difficult forceps delivery. Birth weight was 4.5 kg and gestational age was 40 weeks. Infant is being monitored for potential complications.
Poor Documentation Example:
Infant injured during birth.
Common Documentation Errors:
- âš Not documenting the specific type of injury
- âš Not documenting the cause of the injury
- âš Not documenting any associated conditions or complications
- âš Not documenting the infant's birth weight and gestational age
Range Statistics
Coding Complexity
Coding for birth trauma can be complex due to the need to understand the specific types of injuries, identify the cause of the injury, and code for any associated conditions or complications. The level of specificity required can also add to the complexity. However, with a good understanding of the guidelines and regular updates, it is manageable.
Key Factors:
- â–¸Understanding the specific types of birth trauma
- â–¸Identifying the cause of the injury
- â–¸Coding for associated conditions or complications
- â–¸Determining the appropriate level of specificity
- â–¸Keeping up-to-date with the latest ICD-10-CM guidelines
Specialty Focus
These codes are most commonly used by obstetricians, pediatricians, and neonatologists. They provide specific information about birth trauma, which can be crucial for the management and prognosis of the infant.
Primary Specialties:
Clinical Scenarios:
- • Infant with skull fracture due to vacuum extraction
- • Infant with brain injury due to hypoxic-ischemic encephalopathy
- • Infant with brachial plexus injury due to shoulder dystocia
- • Infant with facial nerve palsy due to forceps delivery
- • Infant with multiple injuries due to precipitous delivery
Resources & References
There are several resources available for coding birth trauma. These include the ICD-10-CM official guidelines, clinical reference books, and educational materials from professional coding organizations.
Official Guidelines:
- ICD-10-CM Official Guidelines for Coding and Reporting
- American Health Information Management Association (AHIMA) guidelines
- American Academy of Professional Coders (AAPC) guidelines
Clinical References:
- Clinical Coding Workout by AHIMA
- ICD-10-CM Expert for Hospitals by Optum360
Educational Materials:
- ICD-10-CM Coding Handbook by AHA
- ICD-10-CM and ICD-10-PCS Coding Handbook by Nelly Leon-Chisen
Frequently Asked Questions
Can I use a P10-P15 code for an injury that occurred after birth?
No, the P10-P15 codes are specifically for injuries that occur during the birthing process. For injuries that occur after birth, you should use the appropriate code from the P00-P96 range.